Provider Demographics
NPI:1255903415
Name:WISE, CARLY SIMONE
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:SIMONE
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CAULK LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-8000
Mailing Address - Country:US
Mailing Address - Phone:270-403-3493
Mailing Address - Fax:
Practice Address - Street 1:103 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:MUNFORDVILLE
Practice Address - State:KY
Practice Address - Zip Code:42765-9023
Practice Address - Country:US
Practice Address - Phone:270-696-3181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator